Concussion and Post-Concussion

Spectrum of Symptoms

Ross Zafonte, DO

Department of Physical Medicine and Rehabilitation,

Spaulding Rehabilitation Hospital and Harvard Medical School, Boston, MA

Mild TBI

Concussion

▪ Direct blow or impulsive force transmitted to the head

▪ Rapid onset of short-lived impairment of neurologic function that resolves spontaneously

▪ Symptoms may evolve over minutes to hours

▪ +/- LOC

▪ No structural abnormality on standard neuroimaging

Complicated Mild TBI

▪ GCS 13-15

▪ Trauma-related intracranial

abnormality (e.g.,

hemorrhage, contusion, or

edema)

Giza CC and Hovda DA. The New Neurometabolic Cascade of Concussion.

Neurosurgery 2014; 75(04):S24-S33.

Girls Boys

Competition Practice Competition Practice

Soccer 21.8 2.14 9.34 1.04

Basketball 12.1 1.55 4.11 1.24

Lacrosse 10.01 1.66 13.04 1.46

Softball/Baseball 3.93 1.43 2.08 0.47

Swimming 0.79 0.63 0.45 0.35

Track & Field 0.69 0.19 0.4 0.12

Cross Country 0.3 0.1 0 0.07

Sex-Comparable Sports Total 9.64 1.09 3.9 0.63

Kerr ZY, Chandran A, Nedimyer AK, et al. Concussion incidence and trends in 20 high school sports. Pediatrics. 2019. 144(5): e20192180.

Observable signs

▪ LOC (uncommon)

▪ Balance disturbance

▪ Amnesia (retrograde/anterograde, often very brief)

▪ Disorientation

▪ Confusion/attentional disturbance▪ Slowness to answer questions/follow

directions

▪ Easily distracted

▪ Poor concentration

▪ Vacant stare/“glassy eyed”

▪ Inappropriate/confused playing behavior

Slide adapted from G. Iverson

Reported symptoms

Common

▪ Headaches (78.5%)

▪ Fatigue (69.2%)

▪ Feeling slowed down (66.9%)

▪ Drowsiness (64.2%)

▪ Difficulty concentrating

(65.8%)

▪ Feeling mentally foggy

(62.3%)

▪ Dizziness (61.2%)

Less Common

▪ Nervousness (21.2%)

▪ Feeling more emotional

(17.7%)

▪ Sadness (15.0%)

▪ Numbness or tingling

(14.6%)

▪ Vomiting (8.8%)

Lovell et al. 2006

Premorbid issues count!Pre-morbid Issues Count!

▪ Leading cause: falls• Risk increases with age1

▪ Causes of falls2

• Neuropathy• Vision problems• Polypharmacy• Orthostasis• Cognitive difficulties • Stroke / leg weakness • Slow reaction times

1. Coronado VG, Thomas KE, Sattin RW, et al. The CDC traumatic brain injury surveillance system: characteristics of persons aged 65 years and older hospitalized with a TBI. J Head Trauma Rehabil. 2005;20(3):215-228.

2. Meyer KS, Jaffee MS, and Grimes J. Military Traumatic Brain Injury: Special Considerations. In Zasler ND, DI Katz and RD Zafonte. Brain Injury Medicine, 2nd Ed. New York, NY: Demos Medical; 2013.

MTBI: Elderly

Persistent post-

concussive symptoms

▪ Majority recover within 2-4

weeks

▪ 30% may experience

symptoms beyond 1 month

▪ Problem:1

▪ Symptoms largely nonspecific

▪ Symptoms don’t occur consistently in “syndromic” pattern

▪ Symptoms also occur in health population

▪ Disagreement on etiology and prevalence2-4

▪ Validity of diagnosis in question by many1

1. Iverson GL, Silverberg N, Lange RT, et al. Conceptualizing Outcome From Mild Traumatic Brain Injury. In Zasler ND, DI Katz and RD Zafonte. Brain Injury Medicine, 2nd Ed. New York, NY: Demos Medical; 2013.

2. Iverson GL. Outcome from mild traumatic brain injury. Curr Opin Psychiat. 2005;18:301-317.3. Ryan LM, Warden DL. Post concussion syndrome. Int Rev Psychiatry. 2003;15:310-316.4. Evered L, Ruff R, Baldo J, et al. Emotional risk factors and postconcussional disorder. Assessment. 2003;10:420-427.

“Post Concussive

Syndrome

▪ Definition of “syndrome”

• 1-2 symptoms ≠ syndrome

▪ Classic “constellation” of symptoms:1

• Cutoff of < 3 Sx: too liberal?

• Non-injured patients likely to have somesymptoms

▪ “Clinical significance” criteria2

• Functioning impacted as defining poor outcome

1. Iverson GL, Silverberg N, Lange RT, et al. Conceptualizing Outcome From Mild Traumatic Brain Injury. In Zasler ND, DI Katz and RD Zafonte. Brain Injury Medicine, 2nd Ed. New York, NY: Demos Medical; 2013.

2. Snell DL, Siegert RJ, Hay-Smith EJ, et al. Factor structure of the brief COPE in people with mild traumatic brain injury. J Head Trauma Rehabil 2011;26:468-477.

Prevalence of Persistent

Symptoms

Traditional Rx = Rest

▪ Symonds 1928- rest until symptom improvement followed by

gradual return to normal activities

▪ Traditional treatment approach = physical and cognitive rest

until symptom free

▪ Mitigate post-concussion symptoms

▪ Promote recovery by minimizing energy demands on the

brain

Does prescribing physical and cognitive rest achieve

these goals?-not so much!

Challenges

▪ What is considered rest?

▪ Avoid certain activities

(sports, chores, texting,

watching TV)?

▪ DiFazio et al. 2016-

“withdrawal from usual

preinjury life activities

including academic,

social, recreational, and

athletic”

▪ Adherence to rest

recommendations is

challenging

▪ Rest ≠ lack of brain activity

▪ When should rest be ended?

▪ “If some rest is good,

more is better”

Impact of prolonged rest

▪ Inactivity has been shown

to prolong recovery from

many health conditions

(Silverberg and Iverson

2013)

▪ Vestibular disorders

▪ Depression

▪ PTSD

▪ Chronic fatigue

▪ Pain disorders

▪ Removal from validating

life activities (DiFazio et

al. 2015)

▪ Physical

deconditioning

▪ Psychological distress

▪ May promote

persistence of post-

concussive symptoms

Slide courtesy of M. Alexis Iaccarino

Prolonged rest after

concussion

▪ Likely detrimental to recovery

▪ Physical deconditioning

▪ Depression and anxiety

▪ Sleep-wake cycle disturbance

▪ Rumination

▪ Symptom amplification

Slide adapted from M. Alexis Iaccarino

Impact of rest

▪ de Kruijk et al. 2002

▪ No benefit of complete bed rest after mTBI on

posttraumatic complaints or general health status

▪ Thomas et al. 2015

▪ Longer time to reach symptom resolution and more post-

concussive symptoms after strict rest vs. usual care

▪ Buckley et al. 2016

▪ Additional rest did not short duration of symptoms or

result in quicker return to baseline

RestAvoiding Contact

Avoiding contact protects the patient from sustaining another injury

Slide courtesy of M. Alexis Iaccarino

Rest protects the patient from

sustaining another injury

Prolonged Rest

▪ Cocoon therapy and sensory deprivation

▪ Avoidance of all visual, auditory, social, intellectual, and physical stimulation

▪ No evidence of benefit (Silverberg et al. 2014)

▪ Not indicated in concussion recovery

Slide adapted from M. Alexis Iaccarino

Rationale for rest?

▪ A period of rest following injury is advisable

because: I. It protects the patient from sustaining another injury

during a period of vulnerability

II. Physical and cognitive activity often exacerbate

symptoms and associated impairments in the post-injury

period

McCrory et al. Br J Sports Med 2013 Slide adapted from M. Alexis Iaccarino

Early diagnosisRelative

restActive rehabilitation

Multidisciplinary

Slide courtesy of M. Alexis Iaccarino

Recovery after mTBI

Safety and feasibility

▪ Leddy et al. 2010

▪ Post-concussion

syndrome

▪ 12 graded aerobic

treadmill tests

▪ No adverse events

▪ Cordingley et al. 2016

▪ Pediatric sport

concussion

▪ 141 graded aerobic

treadmill tests

▪ No adverse events

▪ No persistent

concussive symptoms

or elevation in

physiologic parameters

Slide courtesy of M. Alexis Iaccarino

Return to learn

McCrory et al., Br J Sports Med 2017

Return to play protocol

McCrory et al., Br J Sports Med 2017

Athlete

Neuro-

psychologist

Sport

psychologist

Physician

Physical

therapist

RNSchool

Athletic trainer

Coach

Parents

Multidisciplinary Team

Visual – Vestibular - Trajectories

▪ >50% of brains pathways and cranial nerves impact visual function

⁻ Directly:

» CN II (visual acuity, visual fields, pupils)

» CN III, CN IV, CN VI (oculomotor)

⁻ Indirectly:

» CN V (sensory)

» CN VIII (via VOR)

▪ CN III, IV and VI innervate the eye muscles, exit the brain stem, travel along base of skull, join behind the eye and enter orbit - susceptible to injury anywhere along the route from BS to eye muscles

Implications on vision after

concussion

Causes of dizziness related to vestibular system:▪ Central (10-15%)• Post concussion spectrum of symptoms• Migraine (in patients with and without concussion)

▪ Peripheral (40%)• BPPV (benign paroxysmal positional vertigo)• Labyrinthine

− Meniere’s− Fistula

• Vestibular nerve damage▪ Other • Cervical receptors• Psychiatric disorder (anxiety) (15%)• Presyncope (25%)• Nonspecific dizziness (10%)

Implications on vestibular system

after concussion

For a narrative description and guideline recommendations related to this algorithm, please refer to Section 6.

Limit Usage:

* < 15days

permonth

** < 10 days

per month

Assessment and Management of Post-Traumatic HeadacheFollowing mTBI

Assessment

1. Take a focused headache history exam (Table 6.1).

2. Determine type of headache presentation (Appendix 6.3).

3. Determine degree of disability and medication consumption.

4. Perform neurological and musculoskeletal exam (Appendix 3.4).

Non-Pharmacological TreatmentPharmacological Treatment

Self-regulated intervention & lifestyle strategies

to minimize headache occurrence (Appendix 6.6)

Consideration to intermittent passive therapies

(relaxation therapy, biofeedback, massage

therapy, manual therapy etc.)

Was this treatment successful?

No Yes

Pharmacological

intervention.

Referral is

recommended.

Monitor

symptoms and

continue therapy if

indicated

Tension/Unclassified Migrainous

1. Over-the-counter or

prescription NSAIDs *

2. Acetylsalicylic acid *

3. Acetaminophen *

4. Combination

analgesics (with

codeine/caffeine) **

Triptan class medications **

(i.e., almotriptan,eletriptan,

sumatriptan, rizatriptan,

zolmitriptan, etc.)

Successful? Yes

Monitor

symptoms &

continue

therapy.

No

Is patient a candidatefor

prophylactic treatment?

No Yes

Referral is

recommended.Prophylactic

Treatment

Amitriptyline

Other TCAs

Venlafaxine XR

Tizanidine

Adjunctive

therapy

Successful?

Yes

No

Continue

treatment for

6-12 months,

then reassess.

Try different

first-line

medication or

drug of same

class.

Prophylactic Treatment

Assess factors thatmay

trigger migraine.

Medication(beta-

blockers, tricyclic

antidepressants)

Anti-Epileptic

Drugs

(divalproex,

topiramate,

gabapentin,

verapamil)

Reinforce education &

lifestyle management

(Appendix6.7)

Consider passivetherapies

Screen for depression

and generalized

anxiety

Successful?

No Yes

Successful? Yes

Try combination

of beta-blockers

and tricyclics.

No

Successful? YesNo

Ontario Neurotrauma

Headache

SleepAssessment and Management of Sleep-WakeDisturbances Following mTBI

Every person with mTBI who has identified sleep problems should be

screened for sleep-wake disturbances (see Appendix 7.2 and 7.3),

such as insomnia or excessive daytime sleepiness.

Yes

Screen for medical conditions, current medication use, comorbid

psychopathology, and risk factors for sleep disturbances (see Table

All patients with persistent sleep-wake complaints should be placed on

a sleep hygiene program (see Appendix 7.4) in addition to other

interventions.

Sidebar 1: Medications

Potential Medication Options – short-term basis

only

1. Trazodone

2. Mirtazapine

3. Tricyclic antidepressants (amitryptyline)

4. Prazosin (for PTSD + nightmares)

Avoid benzodiazepines

Note: Non-benzodiazapine medications (zopi-

clone, eszopiclone) may have fewer adverse

side-effects.

Non-Pharmacological TreatmentPharmacological Treatment

Assessment

If medications are to be used, ensure they do not

produce dependency and that they have minimal

adverse effects for mTBI patients. The aim is to

establish a more routine sleep pattern (Sidebar 1).

Consider Daily Supplements

magnesium, zinc, melatonin

Refer for sleep specialist consultation (ideally one

with experience with mTBI and polysomnography).

Do sleep disturbances persist?

NoYes

Is there a suspicion of sleep-related

breathing disorders, nocturnal seizures,

periodic limb movements, or narcolepsy?

NoYes

Cognitive Behaviour Therapy (CBT)

The treatment of choice for either primary insomnia or insomnia

comorbid to a medical or psychiatric condition.

Behavioural

recommendations of sleep

restrictions and stimulus

control can be implemented

with weekly monitoring of the

patient for the first few weeks

(Appendix 7.5).

Is CBT unavailable to the patient or is the patient waiting

for CBT treatment?

Yes No

Was CBT successful?

Yes No

Other Treatment Options

Acupuncture, exercise,

mindfulness-based stress re-

duction, magnesium and zinc

supplementation

Continue to treat and monitor sleep-wake disturbances. Refer for

sleep specialist consultation (ideally one with experience with mTBI

and polysomnography) if unable to manage sleep disturbances.

For a narrative description and guideline recommendations related to this algorithm, please refer to Section 7.

Ontario Neurotrauma

Behavioral HealthAssessment and Management of Mental Health DisordersFollowing

concussion/mTBI

Assess for:

• Depressive disorders (see Appendix 8.1)

• Anxiety disorders (see Appendix 8.2)

• Post-traumatic stress disorder (see Appendices 8.3 and 8.4)

• Substance use disorders (see Appendix 8.5)

• Other conditions that may require specific attention/management

(refer to narrative in Section 8)

Based on the screening scales, determine the severity of any

persistent mental health disorders.

** Medication Considerations

• Use caution to minimize potential adverse effects

• Begin therapy at lowest effective dose and titrate based on tolerability

and response

• <1 medication change at a time

• Regular follow-ups are necessary

Non-Pharmacological Treatment

Assessment

If Mild/ModerateConsider management by local PCP.

General Measures:

• Support and psychoeducation re: proper sleep

hygiene; regular social and physical activity

Psychosocial Interventions

Evidence-Based Psychotherapy:

• Cognitive behavioural therapy (CBT); trauma-

focused therapy for PTSD

Other Psychotherapy Interventions:

• Depending on availability

Was the treatment successful?

Yes

Monitor symptoms and continue therapy.

No

If Severe

Consider referral to a psychologist or psychiatrist as required.

Non-Pharmacological

TreatmentPharmacological

Treatment**

General Measures Psychosocial

Interventions

Evidence-Based Psychotherapy:

• CBT; trauma-focused therapy for

PTSD

OtherPsychotherapy

Interventions:

• Depending on availability

Anxiety/Mood Disorders

1st Line: SSRI

2nd Line: SNRI, mirtazepine, TCA

PTSD

1st Line: SSRI

2nd Line: SNRI (venlafaxine)

PTSD and SleepDisruption

Trazadone, mirtazapine, prazosin

Pharmacological Treatment **

Anxiety/Mood Disorders

1st Line: SSRI

2nd Line: SNRI, mirtazepine, TCA

PTSD

1st Line: SSRI

2nd Line: SNRI (venlafaxine)

PTSD and Sleep Disruption

Trazadone, mirtazapine, prazosin

Was the treatment successful?

No

Referral to a psychologist or psychiatrist.

Yes

For a narrative description and guideline recommendations related to this algorithm, please refer to Section 8.

Ontario Neurotrauma

Conclusions

▪ Relative rest (24-48 hours) after concussion

▪ Prolonged rest may be detrimental to recovery

▪ Exercise induces molecular, neuroplastic, and

neurovascular changes in the brain

▪ Submaximal, subsymptom threshold exercise likely safe

▪ Active rehabilitation via multidisciplinary approach

likely best

Thank you